A Funny thing Happened on the way to Meaningful Use

This July will mark the 16th anniversary of the installation of our electronic medical record.
Yup. I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn't afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka "meaningful use" criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind. No, I didn't stop thinking that EHR was a very powerful tool that could transform care. I didn't pine for the days of paper charts (whatever they are). I certainly didn't mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven't. In fact, they've made things much worse.

We first installed EHR in 1996, after we were scared by an abnormal Chest X-Ray that was missed due to our paper charting system. We were afraid we were giving bad care for our patients, and saw computers as the solution. Ironically, our success with our implementation hinged on our non-conformity with our EHR product's design. We didn't care if we used every part of the product, instead focusing on only using things in a way that improved the care without hurting our office workflow. Early on, we used a hybrid of paper and computers to give us the information in the proper format. Then, once our vendor opened up the product to customization, I totally abandoned the hideous clinical content they had made, designing my own forms that maximized both quality and efficiency.

But last year, our first year in the "meaningful use" era, our focused changed in a very bad way. We started talking more about our EHR complying to criteria than maximizing quality and efficiency. Our vendor jumped on this bandwagon, ignoring the fact that they were stuck in a pre-internet, office-network design, and instead put all of their resources into letting their users meet "meaningful use." In the past, the computers were a tool we used to help our patients; with "meaningful use" they became a distraction, taking us away from a clinical focus and driving us toward proper data-gathering.

This is sadly ironic. We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for "meaningful use." This should come as no shock to anyone who has watched American health care over the past 20 years. We have beaten doctors over the head with "clinical pathways," and "evidence-based medicine," all with a good intent: to make sure doctors gave good care. The problem was, however, that these criteria become more important than the patients they were meant to serve. The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.

So what can be done? I don't really know. I still do believe that universal acceptance of EHR, coupled with patient data flowing efficiently between points of care, could improve quality and save a bus-load of money. But I am not so sure about where we are heading. I want to use computers for the benefit of my patients, not for the sake of compliance to the guideline de jour, or the next great government incentive program.

To paraphrase a famous political campaign motto: it's about the patient, stupid.

So I am working to somehow comply with government guidelines (and get my incentive check so I can have a better shot at paying for four kids going through college in the next 10 years) but doing so while somehow not losing focus on the patient. I have to say, it's a very hard thing to do.

My dream of universal acceptance of EHR has turned sour. I am beginning to hate the words: "meaningful use." I am starting to fantasize about a life without it, and maybe even a life without anybody else's definition of what the care I give should look like. I want to be a doctor. I want to take care of my patients. I want them to be the most important thing, not the other people enticing me with their big checks. Can I stay in our system while still giving care that is meaningful?